Healthcare educational leadership in the twenty-first century

Abstract

Education leadership has to intimately lead our future champions of students and nurture them as professional, dynamic, reflective scholars to deal with the complex world of healthcare in a post-truth era. In addition the organization structure needs to develop faculty from clinical and educational supervisors through to program directors and Deans. Leadership theories have taken over from the previous decades of teaching on management. The current dogma is intransigent, and produces silos such as leadership and followership or leaders and managers as class differences which reinforces the obdurate and narrow-minded approach. This contradicts the open society of creating change agents, critical thinkers, and scholars of the conceptual age of post modernity who in a knowledge based economy need to take our world forward. Additionally healthcare is rapidly becoming unaffordable as returns on GDP investment do not give the returns that we as patients and tax payers need. There is the obvious waste of people and funding on constant reorganizations and short-term thinking. This reflects the sort of leaders and organizations we are developing and how decisions are made. This paper through ideas confronts the myths and flaws of current leadership teaching in an education framework. It makes the case for innovative, creative, adroit, adept, experiential learners who can see the bigger picture, avoid harm and be able to cope with complexity and uncertainty, thereby creating a paradigm shift so that future leaders can problem solve, through the ongoing seismic changes that healthcare faces.

Introduction

Healthcare is probably the highest priority for most citizens in a country. How we educate and motivate our health professional students and faculty is essential to make our patients better (Frenk et al. 2010). The latter is the central theme of health professions’ education. Socrates defined “education as the kindling of a flame and not filling of a vessel”. It is the lighting of those sparks that drive us and not the drone of ever expanding tomes of information but little understanding. Educational leadership is eclectic and can no longer be hierarchical, top-down dealing just with facts, but has to be the lived experience of the leader. Unfortunately words have become the default thinking which is not enough. Reflection at the heart of educational leadership is the ability to step back, see what is working, what has been achieved and where further development needs to take place. We need the next generation to move on from dogma and the status quo, and through critical thinking, question what they see together with the resulting outcomes. Dewey (1944) and Schon (1987) insightfully define “education as the reorganization of experience”. Therefore, reflection is a key part of learning.

In the realm of social deprivation the strength of education helps us to focus on our professional roles and the most significant aspects of our lives. Education has the power to extend our abilities beyond those that nature has originally endowed us with, and compensate us for certain frailties and in born weaknesses. Above all education as a medium is therapeutic. It can confront, challenge, stretch, guide, exhort and console us thereby enabling us to become better versions of ourselves, and in so doing, have a direct impact on the care of our patients and their outcome.

Table

Practice points

Leadership improves patient outcomes by managing robustly the impact of demographic changes. Better use of resources through transparent performance management. Motivation drives creativity, innovation and resilience. Improves morale of the organisation which includes students, faculty and managerial staff. Enhances ability to cope with reduced budgets for education and increasing demands of health care. Improves ability to handle change and chaos.

Educational leadership is not just about training but also development. This is not a linear process and there is the need to cultivate the talents and sensibilities through which we can care for patients and create the best future for us all (Robinson and Aronica 2009).

Leadership influences our thinking, actions and ultimately, these decisions affect our healthcare systems and patient care. This is even more imperative now, as there has been a shift of the hierarchy of “healthcare power” from professionals to patients and relatives, who are conscious of the incidents of abuse and neglect of patients, and now question what are the values of the modern UK NHS (Francis 2013).

The recent 2016 General Medical Council (GMC) national training survey of 50,000 junior doctors in training (98.7% response rate), picked up some demotivating trends of 43% feeling their education was being comprised by a heavy service load, and 25% reported feeling short of sleep on a regular basis. Opting out of educational activity was one way of coping with the stress of an arduous shift. The GMC emphasize the need to be vigilant and take action where necessary. Training time is essential for doctors to gain the knowledge, skills and experience they need (GMC 2016). Knowledge is a way of seeing and leads to empowerment. The need to survive the current pressures of a shrinking economy and increasing demand of healthcare, with the projected impact of more chronic diseases related to the demographic changes is essential. With expensive interventions, including technology, diagnostics and pharmaceuticals, cutting edge leadership within an innovative environment is crucial. The culture of the organization and moving from being an authoritative boss to becoming a leader will be important. Innovation is a culture created through conversations and ideas that function as liquid networks (Johnson 2011). A way of working and thinking. Doing more for less. Doing new things and existing things better. Innovation ultimately brings into existence something new that can be sustained and repeated and which has value (Robinson and Aronica 2009). Innovation is intimately linked with leadership, and innovative leadership is a recognized term and is defined as a discipline that combines different leadership styles to produce creative ideas, products and services (Adjei 2013). However, the definition is incomplete as all leadership has also to cope with complexity and uncertainty.

The following factors would have an impact in giving educational leadership a higher profile:

• Improves patients’ outcomes (Francis 2013).

• Change is a natural process and the default position. Understanding this is a necessity as it closes the gap between the current level and where the vision drives performance.

• The pace of organization development has become much faster.

• There is much more transparency into how decisions are made and resulting accountability. Thus failure to progress due to poor judgment is pellucid.

• A strong drive on performance management.

• The global market in healthcare and education driving quality through competition.

• The impact of new technologies and processes allowing organizations to think innovatively to ensure continued success and remain competitive.

• Increasing understanding of diversity and human behaviors through Myers – Briggs type indicator (Myers and McCaulley 1985), Johari Window (Luft and Ingham 1955) and the theory of Multiple Intelligences (Gardener 1992).

• Moving away from fixed point and stable predictions to chaos, complexity and uncertainty (Stacy 2010).

This explosion has led to many theories on leadership and impact of leadership styles. Any concept that has many theories means that there is not a perfect theory.

One of the major flaws in leadership theory is that successive authors are dogmatic (Sandhu 2014). The reality is that succeeding decades and authors have made a contribution. Science builds on previous learning and this is an iterative process. Unfortunately the teaching on this inflexible theme has led to an acceptance of an intransigent doctrinaire. Progression is based on making an impact which inevitably involves being innovative and driving those creative ideas to fulfillment.

Historically we are brought up with heroic leaders. In the ancient world these often consist of military or spiritual leaders. For thousands of years before writing there was a strong oral tradition and heroic leadership became deep-rooted within our psyche. There is therefore a challenge and a difficulty to change from the heroic to the transformational or other models.

Education can drive innovative leadership by touching our world of ideas, complexity and uncertainty (Sandhu 2014). Innovative leaders are highly intelligent, absorb, understand and integrate new ideas and information and are sensitive to the needs of their organizations. The development of the healthcare workforce is intrinsically linked with education and training and there are many successes in the NHS (Lees et al. 2010).

For healthcare systems, evidence based medicine has to be developed hand in hand with evidence based management and organization development. In effect the complexity of healthcare systems cannot be solved by a single profession. Better leadership is the long term strategy and seen as central to improving the quality of healthcare and the improvement of organizational processes (Hartley and Benington 2010). A revolution of mind set is required as we deal with the new “wicked” changes; increasing longevity of life with chronic disease burden, life style choices such as obesity, smoking, alcoholism, drug addiction as well as the social pressures of unemployment and poverty. Such social deprivation does mean that public health and prevention of diseases has now taken the central stage and innovative ways of teaching medicine are evolving (Sandhu and Waddell 2016). Health promotion and not just sickness alleviation is a priority.

What is leadership?

The term leadership embodies “lead” and “ship” and is about managing people to get the job done (Owen 2012). Yukl (2002), expands leadership further as “the process of influencing others to understand and agree about what needs to be done, how it can be done effectively, and the process of facilitating individual and collective efforts to accomplish the shared objectives” (Yukl 2002). Therefore, leadership goes beyond vision into values, aims and goals. Leadership does not start from scratch and has to work within the culture of the organization. It is distinct from the position of authority and takes place every day (Heifetz 1994). It is not the trait of the chosen few nor a once in a life time opportunity. It is both active and reflective and therefore has to alternate both between participating and observing. We are aroused about leadership because it engages our values and is associated with something we prize. When we tackle problems we discover our true values (Heifetz 1994).

At the innovative level, leadership involves learning to think and appreciate that the process of learning is more than doing a task or activity. If in education, innovative leaders are to develop then they need to learn from reflection and grasp that the latter is not a passive exercise. Caring for our profession and patients, means that qualities of clinical reasoning and critical thinking have to be developed in our students and trainees. Clinical reasoning is the cognitive process associated with clinical practice which requires observation, knowledge and skills to form a judgment that informs the clinical decision in patient management. Critical thinking is the ability to solve complex problems effectively. The competence to interpret argument, evidence or raw information in a logical and unbiased fashion.

Leaders are not necessarily people who make a paradigm shift. That is unusual. Most people have leadership in them and so leadership is a natural expression (Radcliffe 2012) and people demonstrate both leadership and situational awareness through emotional intelligence (Goleman et al. 2008). Transactional leadership driven by targets, coupled with a lack of insight has led to disastrous outcomes and the exact opposite of those intended (Francis 2013).

Leadership and followership

There is much confusion about the relationship between leadership and followership. To observe and reflect are necessary in both leadership and followership. Personal power states Mary Parker Follett arises from group power as followership is not a passive activity and paradoxically a powerful form of leadership (Graham 1995; Owen 2012). There is a dynamic connection between the leader and the follower. Both follow the “invisible leader” – the common purpose, and it is the success of the team that makes the leader. We therefore need to foster relationships to make change related decisions. This involves conversations, mentorship, coaching, including colleagues in experimentation, reward and recognizing good work and creativity. Above all the “L” in leadership stands for listening. In a team no single person can lead (Belbin 1981). Others with strengths in their skill sets should be allowed to express themselves and given credit for their active followership. Therefore, leadership is intertwined with followership; they are two sides of the same coin.

Management and leadership

The second imposter is the debate between management and leadership. Kotter (1990) defines management as coping with complexity. This involves planning, budgeting, organizing, staffing as well as controlling and problem solving. He sees leadership as coping with change. Kotter’s view is that leaders set the direction, develop the vision, align the people and motivate and inspire them. Managers have authority to accomplish certain tasks. However in the modern setting every manager has to have leadership skills and all leaders must know how to manage and run their budgets. The differences are historical and now immaterial and the roles are inter-changeable. The old world managers were thought of as blockers and cut budgets and made life difficult for patients and healthcare staff. The twenty-first century manager has to completely buy into the vision and mission of the organization. A manager has to be someone who fights for better budgets, creates processes to make sure clinical directorates work and through efficient and effective means ensures there is better care for patients as well as staff development. Management in healthcare can be defined as “ensuring patient safety and health through effective use of resources to drive the vision of the organization through”. Managers and leaders both occupy a leadership role within the organization. So there is a convergence and they both need to manage the limited resources of people and budgets for maximum effectiveness.

Drucker’s current view of strategic thinking of leadership has six levels consisting of: Vision, mission statement, goals, objectives, action points and resources to deliver on the above (Drucker et al. 2015). The concern he has is that these are simplistic and do not go into depth of the complexity and at times, contradictory behaviors and knowledge. Educational leaders need to consider the following points:

Mission

This is the organization’s reason for being, its purpose – not the how. Why do you do what you do? Says what in the end you want your organization to be remembered for (Drucker et al. 2015). The mission statement should inspire and allow us to reaffirm our values. It must be clear, powerful, compelling, and to the point. The simple questions are the hardest to answer because it requires us to make stark and honest self-assessment. The difficulty is that in many organizations the workforce makes no connection with the mission statement which is often crafted by senior management and bears little relationship to what is going on at the coalface. Thus, on two yearly reorganizations the workforce may come across many mission statement versions, all meaningless and containing none of the purpose of the organization.

Vision

Vision is a picture of the organization’s desired future. This relates to where we are and where we want to get to. This is the traditional role of the chief executive. The time span of a CEO is short, so they are under pressure to be ambitious, but, if the vision is not realistic the experienced workforce who are already dejected will discard it. Within the futility and banality of constant reorganizations the rhetoric seems to be strong but usually fails to get buy in. The reasons why the vision fails is that it focuses on the future which does not exist, is unpredictable and uncertain and ignores the present which does exist, and crucially where the problems lie. Instead of focusing on distant horizons – much better to make a careful and through assessment of what is going on in the present, and what must be done now to achieve the vision of tomorrow. This future has to be created by the team and not an individual (Graham 1995).

Goals

Goals need to be realistic and limited. More than five are not goals but a never ending circus. A set of three to five goals is ideal that set the organization’s fundamental long-range direction and its true compass. In developing the goals there will be the need to identify strengths and challenges, embrace change, foster innovation, accept and respond to patient feedback, look beyond the organization for trends and opportunities, encourage planned abandonment and demand measurable results.

Results

This should define the organization. Results can change lives, people’s behavior, circumstances, health, hopes, competence, and capacity. As Drucker says they are ultimately what you are judged by (Drucker et al. 2015). Before a vast fortune is spent on PR and communication companies that do not know the organization, the honest self-evaluation with the coal face is essential to estimate what has been achieved and what needs further work or investment.

Budget

The budget defines the organization and shows the commitment of resources necessary to implement plans that are laid out in the institution’s goals. Within medical education we correctly first learn how to make patients better through the practice of good medical training. There is no training on how budgets are determined and managed. In an educational leadership role such as a simulation lead or training program director, the realization soon hits that without a budget, there can be no vision, mission or goals. The second lesson is that spending money in institutions is difficult. Many departments underspend because of poor planning, and the process of spending is laborious and not transparent. There is an art of first making an educational case. In what way does this spend benefit the individual, the department or the organization? Does the request fit in with the aims of the organization? Will it enhance its reputation? Following the educational case the next step is to make the business case. This needs to define where the budget will come from? Is the budget already approved or additional funds will be needed, and if so from where? The business case must show projected sustainability of the program or development. These are just some of the examples that an educational leadership role will throw up.

The external face of the organization shows how much development and investment has been made. The internal face can show for example such details as the freeze on recruitment and budget cuts affecting staff development and study leave.

Micromanagement prevents the ability to utilize the budget innovatively which could allow greater productivity as well as savings.

Plan

A plan is a concise summation of the organization’s purpose and future direction. The plan leads you to work for results. It converts intentions into action. Objectives are the specific and measurable levels of achievement that move the organization towards its goals. Planning is an iterative process and all senior educationalists need to be involved as theirs is a leadership role and the responsibility that comes with it. Measuring results is a tool for learning.

Planning is frequently misunderstood as making future directions and decisions. Decisions only exist in the present. The question is what we must do today to achieve results tomorrow. Planning involves the continuous process of strengthening what works and abandoning what does not and of making risk-taking decisions with the greatest knowledge of their potential effect. Educational leaders become change agents by affecting lives, changing conditions, people’s behavior, circumstances and their health care. Organizations excellent at adapting change also know what should not change (Drucker et al. 2015).

Challenge the gospel

Leadership requires constant reshaping, refocusing, and never being satisfied. Passion and ideas drive entrepreneurs. Managing uncertainty should be part of one’s DNA. We are in the IT, social media and information explosion ether. This is called the post modernity era. Modernity refers to the period up to the swinging 1960s. People had forgotten the hardship of World Wars 1 and 2; the unemployment and rationing decades. Life was certain. There was a major emphasis upon rational and scientific methods. Economic and social organizations focused upon capitalist production. Unfortunately they also created specialized hierarchical bureaucracies to control decision making. A post-modernity view of leadership would have to include how we can free ourselves from such constraints. If modernity was about order then post-modernity is about uncertainties, doubts, questions and concerns (Atkinson 2010). The leadership hierarchy needs to be adaptable. Transformation requires moving people out of the old organizational boxes into flexible, fluid management systems which behave as liquid networks (Johnson 2011). We cannot continue to put people into little squares on a staffing structure chart. Need to look at teams. Look at circles of functions and positions in a staffing design. Hierarchies are not suited to today’s knowledge workers, who carry the toolkits in their heads, as knowledge is tacit.

Boids and swarming theory

Leadership is a messy business with unpredictable and unquantifiable outcomes. We react to the wicked problems that constantly materialize and as in nature with boids (Reynolds 1987). In seeing birds in flight, shoals of fish or termites building hills, there does not appear to be any obvious leaders. It seems the groups respond to their situation. Though there may be chaotic behavior, in the short term, it is predictable. Thus leadership is emergent. It responds to the environment. Similarly swarm intelligence is emergent intelligence that reflects the vision that is created within an organization.

In swarming theory there are many other examples of this type of emergent leadership, including artificial intelligence created by robots (Bogue 2008) and in emergency medicine (Perniciaro et al. 2017). Countless surveys demonstrate that the workforce feels their full talents are not utilized by the organization (Matthews 2014). Many work hard not for financial gain but because they believe in doing a good job. Swarm intelligence expresses professional motivation through three aspects. Professionals enjoy autonomy, ability to master their subject and a strong sense of purpose they can align to. This can allow organizations to harness the motivational power that resides in their staff. People like to get on with their work, so remove the bottle necks. Autonomy and delegation leads to empowerment and trust improves collaboration. Such a culture allows scalability to happen with organizations developing further (Bogue 2008). It is beholden upon us to learn from nature and understand emergent leadership.

Post-truth

Post-truth relates to a situation in which people are more likely to accept an argument based on the emotions and beliefs, rather than one based on facts. For instance fake news in a post-truth world. Evidence is only one dimensional of any argument. Truth has many aspects such as cultural beliefs and values attached to it. Leaders of populist movements trading intellectual vises use sophisticated techniques to connect with people by manipulating social media. Education leadership is about objective listening, reflection, critical thinking and making a judgment to such persuasive arguments as in Aristotle’s ethos or the ethical appeal, pathos or the emotional appeal and logos, the appeal to logic (Perelman and Olbrechts-Tyteca 1973).

Conclusions

For educational leaders their professionalism means a set of values, behaviors, and relationships that underpins the trust the public has in the health care workforce. To be a professional the flaws in leadership theory need to be understood. Each health care worker no matter in which team, has an obligation to be patient centered. Leaders need to develop across every level of the organization. Distributed leadership is a responsibility of all members of the organization. The idea that leadership is a senior role and has to deliver a paradigm shift with little accountability to the rest of the organization is probably the biggest heresy of all and drives away the inherent emergent leadership within us all.

Disclosure statement

The author has no declaration of interest. The author alone is responsible for the content and writing of this article.

Additional information

Notes on contributors

Davinder Sandhu

Professor Davinder Sandhu MD, FRCS(Ed.Urol), FRCS(Eng.& Glas), PGCert.Med.Ed, FRCPE, FDSRCS(Eng), FRCGP (Hons), FFSTEd, FHEA is currently Professor and Head of the School of Postgraduate Studies and Research at RCSI Bahrain. A graduate from London University, he is a Urological Surgeon by background and previously served as Professor of Medical Education at the University of Bristol, and before that was Postgraduate Dean for almost 9 years of the Severn Deanery in the South West of England. He is holder of the Bruce Medal and has a special interest in Leadership and Organizational Change.